Anatomy of the Coronary Arteries and Veins
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Transcript of Anatomy of the Coronary Arteries and Veins
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Anatomy of the coronary circulation
&Angiographic VISUALIZATION
Dr Sandeep Mohanan Department of Cardiology Calicut Medical College 1/10/12
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OUTLINE
• Coronary arterial anatomy
• Variations in coronary circulation
• Coronary venous anatomy
• Angiographic views of coronary arteries
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Coronary arterial anatomy• 1st anatomical drawings- Leonardo da Vinci• Oblique inverted crown
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• The coronary arteries and their major branches are sub-epicardially located
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Epicardial Vessel
Subepicardium
Subendocardium
Myocardium
Pericardium (Epicardium)
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• LCA ostium ~ 4mm• RCA ostium~ 3.2mm
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The LEIDEN convention• Each artery arises from respective aortic sinuses - Right coronary sinus(anterior) - Left coronary sinus(left posterior) - Non-coronary sinus(right posterior)
1R2LCx pattern
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Right coronary artery~ 9.8cm 1)Conus artery/ Infundibular/ Third coronary/
Adipose /Arteria of Vieussens- Separate ostium in 23% - 51%- Circle of Vieussens
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Right coronary artery2) Atrial branches of the RCA- < 1mm- SA nodal artery ( Ramus crista terminalis) – 55-65%
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Right coronary artery3) Right ventricular branches- Acute right marginal artery- Ramus crista supraterminalis (Superior septal artery) –
12 -20% , males
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Right coronary artery4) Posterior descending artery- Dominance- Posterior septal branches - < 15mm5) AV nodal artery- 80 -90%
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Right coronary artery6) Postero-lateral branches to the LV
- Inferior wall of the LV
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Clinical division of the RCA• Proximal - Ostium to 1st main RV branch• Mid - 1st RV branch to acute marginal branch• Distal - acute margin to the crux
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Left coronary artery LMCA- 10-15mm(upto 30mm) length & 3-6mm(upto 10mm
diameter)- Trifurcates in 1/3rd : Ramus intermedius/ median artery/ left
diagonal artery/straight LV artery- Rare variations – absent LMCA/ pentafurcation
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Left anterior descending artery - ~ 14.7 cm ; Type I (22%) , Type II & Type III- 2-9 diagonal branches- 90deg bend after turning around P. conus as it gives off 2nd
diagonal branch- Right ventricular branches( left conal/pre-infundibular A)- ~ 10 septal perforating branches (40-80mm X 0.5-1.2mm)
anchors the LAD
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LAD(contd)- 1st proximal septal A is prominent (His Bundle and LBB)- Myocardial bridging – 0.5-1.6% overall (28% in children)- Rarely dual LADs
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Clinical division of the LAD• Proximal - Ostium to 1st major septal perforator• Mid - 1st perforator to D2 (90 degree angle)• Distal - D2 to end
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Left circumflex artery- ~9.3 cm long ; 1.5 -5mm - Left atrial branches- Kugel’s artery (Arteria anastomotica auricularis magna)- LV branches are called the Obtuse marginal arteries
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Clinical division of the LCX• Proximal - Ostium to 1st major obtuse marginal branch• Mid - OM1 to OM2• Distal - OM2 to end
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Coronary segment classification system
• CASS investigators – 27 segments• BARI – 29 segments ( ramus intermedius and
3rd diagonal branch) - Obstructive CAD : > 50% stenosis
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“Dominance”• A misnomer• giving rise to PDA, at least 1 PLV & AV nodal A (BARI classification)
- 85% right dominant - 8% left dominant- 7% co-dominant(70%/ 10%/ 20% – Hurst’s THE HEART)
• Left dominance is 25-30% in Bi-AoV
Gensini GG. Coronary Arteriography. Mount Kisco,NY: Futura Publishing Co; 1975:260–274.
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Nodal blood supply
• Studies on nodal blood supply principally by James (1961) and Hutchinson( 1978)
- James : SA node - RCA 55% & LCA 45% AV node- RCA 90% & LCA 10%
- Hutchinson : SA node - 65% & 35% AV node- 80% & 20%
AV node may have dual supply in 2% cases
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Arterial anastomoses
• Seen at the intracoronary/inter-coronary levels in abundance– significant in development in collaterals in CAD
• Most abundant at the septum
• Intracoronary : 1-2cm X 20- 250 micm• Inter-coronary: 2-3 cm X 20-350 micm
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Coronary artery variations
• 2 coronary artery system is a recent evolutionary acquisition
• Fish and amphibia – 1 coronary artery• Birds – ~ 40% have single coronary arteries.
• 1-5% of those undergoing CAG
Angelini P – Coronary artery anomalies – current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines. Tex Heart Inst J 2002;29:271-278
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Coronary artery variations• Definition of a coronary artery is not based on its origin
and proximal course, but by focusing on its intermediate and distal segments/ its dependent microvascular bed.
Angelini P – Coronary artery anomalies – current clinical issues. Definition, classifications, incidence, clinical relevance and treatment guidelines. Tex Heart Inst J 2002;29:271-278
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• ? Coronary artery Variation vs Anomalies • A broad spectrum of variations of which some
may cause adverse effects• Most of the coronary variations may have no
clinical implications as can be proven by myocardial perfusion studies.
• The regional distribution of a coronary artery, rather than its absolute origin and characteristics.
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A puzzling issue…..
• Proximal course of the LAD may be very different
• LCx may run over atrial or ventricular surface.• An RCA that terminates in the AV groove well
before the crux may not always be an obstruction: 7 – 10% (Grossman)
• Double ostia from the RCS• All 3 arteries from a single sinus• One single artery……………..and so on……
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• The most common coronary variation (Cleveland
Clinic-1,26,000 patients) was separate ostia for LAD & LCX – 0.41% and 2nd commonest was LCX from RCS / RCA – 0.37%
• However, in another series of 1950 angiograms coronary anomalies were seen in 5.6% cases and split RCA (1.2%) was the commonest.
Angelina P. Coronary artery anomalies. Philadelphia, Lippincott Williams & Wilkins, 1999.
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• Level of variables1) Ostium 2) Size 3) Proximal course 4) Mid-course 5) Intra-myocardial ramifications 6) Termination
• MSCT with retrospective ECG gating is now considered the gold standard for characterization of coronary anomalies.
• Prompt a search for underlying CHDs
1) Shi H, Aschoff AJ, Brambs HJ. Multislice CT imaging of anomalous coronary arteries. Eur Radiol. 2004;14:2172-2182. 2) Memisoglu E, Hobikoglu G, Tepe MS. Congenital coronary anomalies in adults: Comparison of anatomic course visualized by catheter angiography and electron beam CT. Catheter Cardiovasc Interv. 2005;66:34-42.
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Abnormal position of ostia• Coronary orifice below the cuspal margin: - 10% RCS- 15% LCS• Coronaries above the sinotubular jn ~ 6% - leads to difficult
cannulation, esp RCA with a high anterior ostium.
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Abnormal number of coronary arteries
• Single coronary artery - 0.024%, usually benign D/d- 2 separate ostia from same sinus, atresia.. Course is important – in 25% a major branch crosses
the infundibulum.• 3 coronaries - 1) Separate origin of conus artery from RCS (36- 50%)2) Absent LMCA with separate ostia for LAD & LCX• 4 coronaries - case reports
• Dual LAD- 0.13 -1% (Morettin ,1976)
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Absent LMCA
• ~0.4%- 1 ostia at the LCS/ 2 ostia in LCS/ 1 ostia in LCS & other RCS- Increased incidence of Left dominance- 6% incidence of bridging- Not usually associated with CHDs- Similar incidence of atherosclerosis- Difficulty in selective cannulation
Topaz et al. Absent left main coronary artery: angiographic findings in 83 patients with separate ostia of the left anterior descending and circumflex arteries at the left aortic sinus.Am Heart J.1991 Aug;122(2):447-52.
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Shepherd’s-crook RCA• ~5% • Acute superiorly angled take-off of the RCA
from the aorta.• Difficult RCA lesion angioplasty
Ethan Halpern. Cardiac CT . Functional anatomy.
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Dual LAD (Duplication)• ~0.13 - 1% of normal hearts• Proximal LAD (LAD proper) bifurcates early into a
short and long LAD -Type I : Short LAD in AIVS, Long LAD on prox AIVS, LV side, distal AIVS
-Type II : Short LAD in AIVS, Long LAD on prox AIVS, RV side, distal AIVS
-Type III: Short LAD in AIVS, Long LAD intra-myocardially in septum
-Type IV: Very short LAD proper and short LAD, Long LAD from RCA
Spindola-Franco H et al. Dual left anterior descending coronary artery: angiographic description of Important variants and surgical implications. Am Heart J 1983:105;445–55.
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Coronary artery Ectasia• 1 - 5% in angiographic series, more in males• 20- 30 % are congenital• Dialatation of a segment to at least 1.5times of the
adjacent normal coronary artery.
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Coronary venous anatomy
• Targeted drug delivery
• Retrograde cardioplegia administration
• Potential conduit to bypass cor. artery stenosis
• Stem cell delivery to the infarcted region
• Access to LA & LV myocardium for arrythmia mapping & ablation
• LV epicardial pacing in CRT
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Coronary venous anatomy
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THEBESIAN veins – Venae cordis minimae
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Conventional coronary venous nomenclature
• Coronary sinus - Thebasian valve• Anterior IV vein(Great cardiac vein) - Vieussens valves - Left marginal vein of LV - Postero-lateral LV vein • Middle cardiac vein• Small cardiac veins
• SEGMENTAL CLASSIFICATION
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Segmental venous classification
• Thus 9 LV venous segments are derived which when added with the conventional classification gives the best comprehensive information to place the epicardial LV leads for CRT purposes
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Retrograde coronary venography
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MDCT angiogram delineating coronary veins along with arteries
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Coronary Angiographic Views• Cardiac Cath 1st by Werner Forssman in 1929• 1st contrast angiography by Chavez in 1947• CART 1st performed by F. Mason Sones in 1958
• a high-resolution image-intensifier television system with digital cineangiographic capabilities.
- Radiograph tube below and Image intensifier above (Flouroscopic imaging system with C-arm)
- Physiologic monitoring system, sterile supplies, resuscitation equipment, Contrast injector (3-8ml/sec) and contrast media
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• Information from a CAG:
CAG helps visualization of the major epicardial arteries up to their 2nd and 3rd order branches
- Coronary anatomy- Characteristics and distribution of coronary stenosis- Distal vessel size- Intracoronary thrombus- Index of coronary flow- Mass of myocardium served- Collateral vasculature
Optimal injection rate: 7ml (2.1ml/s) for LCA and 4.8ml (1.7ml/s) for RCA
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Pitfalls of CAG – A Lumenogram
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Interpretation of the significance of a lumenogram
• Multiple projections from different angles, preferably orthogonal
• Knowledge of the normal calibre of major coronaries: LMCA: 4.5 ± 0.5 mm LAD: 3.7 ± 0.4 mm LCX : 3.5 ± 0.5 mm ( 4.2 mm if dominant) RCA: 3.9 ± 0.6 mm ( 2.8 mm if non-dominant)
• IVUS• Functional studies : FFR
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Mistakes in CAG interpretation• Inadequate number of projections used• Improper/inadequate contrast injection• Super-selective injection• Catheter induced vasospasm• Coronary artery variations• Myocardial bridges• Total ostial occlusions• Wire induced spasm (ACCORDION EFFECT)
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• LAO and RAO views help furnish the true PA and lateral views of the heart
D/A s - foreshortening - superimposition
• Cranial view: Image-intensifier tilted towards head• Caudal view: Image-intensifier tilted towards the feet
-however the optimal angiographic view varies with coronary anatomy, body habitus and location of lesion
Angiographic projections
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Angiographic projections
Kern MJ. Cardiac Catheterization Handbook. 5th edition,2011.
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RAO and LAO projections
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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RAO- LCA
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RAO- RCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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Shallow RAO cranial - LCA
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AP cranial - LCA
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RAO cranial - RCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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RAO caudal - LCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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AP (Shallow RAO) caudal- LCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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LAO - LCA
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LAO - RCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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LAO cranial - LCA
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LAO cranial - RCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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LAO caudal (Spider view) - LCA
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria.CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
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Lateral view
•Mid & distal LAD
•Proximal LCX
•Mid RCA
•LIMA graft to LAD
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Optimal angiographic views for coronary segments
Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976.
There is no single magical projection that can be applied uniformly to all patients for visualizing a particular coronary atery
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Panoramic coronary angiography
GIORGIO TOMMASINI et al. Panoramic Coronary Angiography. JACC 31(4),March 15, 1998:871–7
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References• Hurst’s The Heart 13th Edition • Braunwalds Heart Disease 9th edition• Grey’s Anatomy • Kern’s Handbook of Interventional Catheterization• Kjell C Nikus. Coronary angiography.• Grossman’s Textbook of Cardiac Catheterization• Carlo Di Mario, Nilesh Sutaria. CORONARY ANGIOGRAPHY IN THE ANGIOPLASTY
ERA: PROJECTIONS WITH A MEANING Heart 2005;91:968–976• David M Fiss. Normal coronary anatomy and anatomic variations. Applied
Radiology, Jan 2007.• Horia Muresian. Coronary arterial anomalies and variations. MAEDICA. A journal
of clinical Medicine,1(1), 2006.• Singh et al. The coronary venous anatomy. A segmental approach to aid CRT
2005, 46(1), 68-74. • Shilpa Bhimali et al. A STUDY OF VARIATIONS IN CORONARY ARTERIAL SYSTEM IN
CADAVERIC HUMAN HEART. World Journal of Science and Technology 2011, 1(5): 30-35 ISSN: 2231 – 2587.
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Thank you